Vascular Surgery Fellow AMA

[Jolie South]

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Do you ever feel like fainting during a surgery and if so what do you do to keep your head steady?

No. Only happened to me once when I was super sick.

Students are more likely to have issues. If you feel faint, tell someone and back away from the field. The circulating nurse will help.

 

[LebronManning]

Have you heard about some vascular surgeons being able to build a successful vein practice that incorporates cosmetics?

Also are there some who do dialysis access only? Sounds like it would get boring but might be a nice way to have a heavy case load that makes you a lot of money.

 

[Jolie South]

Have you heard about some vascular surgeons being able to build a successful vein practice that incorporates cosmetics?

Also are there some who do dialysis access only? Sounds like it would get boring but might be a nice way to have a heavy case load that makes you a lot of money.

I don’t know of any that has done veins and cosmetics, though it might be a good idea.

I do know folks at the end of their careers who do only elective dialysis access.

Personally, I think about doing veins, dialysis access, and developing proprietary hosewear as a combination all the time.

 

[mimelim]

Have you heard about some vascular surgeons being able to build a successful vein practice that incorporates cosmetics?

Also are there some who do dialysis access only? Sounds like it would get boring but might be a nice way to have a heavy case load that makes you a lot of money.

I know several vascular surgeons who do veins only + botox/other 'beauty' stuff.

Up to about 6 months ago, I was considering doing essentially dialysis access only. Then again, my concept of dialysis access is probably not what you are talking about. We do 50+ dialysis cases a week where I am training. Also, last week I did an Ax-Atrial graft and a Surfacer TDC (and no, that wasn't an oddball week or anything for us) Hardly boring when there is a non-zero risk of putting a big hole in someone's right heart...

 

[LebronManning]

Have you all ever had a patient code or die in the OR during a vascular surgery case?

 

[mimelim]

Have you all ever had a patient code or die in the OR during a vascular surgery case?

Don't want to steal too much thunder from @Jolie South but, it is pretty hard to not have this happen to you. In the last two months I can remember 3 patients coding on the table. The median ASA class for patients that I have operated on in the last year is 4. It is a part of the job.

 

[Jolie South]

Have you all ever had a patient code or die in the OR during a vascular surgery case?

I have been lucky in that it hasn’t happened since I have been in fellowship, but in general Surgery residency, yes I have.

 

[LebronManning]

Thank you both for your time in answering these questions.

What percentage of your patients are true vasculopaths? By this I mean they’ve been through numerous vascular interventions and they keep coming back due to lifestyle or non compliance?

Conversely what percentage of your patients are “normal” people that happened to have developed the issue you will be correcting. Such as AAA, Carotid stenosis (?), dialysis access, etc?

How do you guys deal with the thought that some work may seem futile due to the recurrent nature of this disease and the non compliance of some patients? Are there a sizable population of compliant and patients with great outcomes that helps you deal with this?

 

[LebronManning]

Also, what's your favorite procedure? I'd guess CEA but that's only based on youtube videos lol.

 

[IJL]

Are you afraid of encroachment from various specialties into VS? Seems like NSGY is doing CEAs (Neusu said he's doing them in 45 mins) and Interventional Cardiology will continue to try to stent everything. I think they have successfully entered the PAD stenting market and would've been more successful with carotid stents if the data with it wasn't so bad. Stents and this data may improve, they may not. And then there's the encroachment from IR onto almost every endovascular procedure you guys do including TEVAR. The advantage here may be that Vascular Surgery, in my opinion, is the MOST qualified to do all of the above. However, history has shown us that this is not always who wins turf wars. To me, a giant advantage of doing GS->VS is the flexibility you were talking about in being able to supplement your practice with GS procedures if VS starts losing turf battles.

Also, how do you deal with the population of vascular surgery patients? I heard they can be very tough in terms of self inflicted disease via smoking, etc. and also their continued non compliance even after you help them. Do you think this is overblown and if not how do you come to terms with this?

IR isn't encroaching on vascular's turf. It's the other way around. Radiologists invented endovascular procedures.

 

[LebronManning]

IR isn't encroaching on vascular's turf. It's the other way around. Radiologists invented endovascular procedures.

Does inventing the procedure make it that specialty's turf if they're not able to manage the perioperative complications? IR also invented PCI but I think we all agree that we'd rather have a Cardiologist with wire skills do these procedures than a physician with maybe even better radiography and wire skills but who is lacking Cardiology knowledge.

 

[DrfluffyMD]

Does inventing the procedure make it that specialty's turf if they're not able to manage the perioperative complications? IR also invented PCI but I think we all agree that we'd rather have a Cardiologist with wire skills do these procedures than a physician with maybe even better radiography and wire skills but who is lacking Cardiology knowledge.

I merely said that IR isn’t encroaching on VS’s turf. Not sure what your musing is all about.

In my opinion, In a perfect world, the patient is best served by a “technique” based system where angiographers do angiography all day and surgeons do surgery all day, while clinicians take care of the peri procedural stuff.

Whereas in the US, you have each organ based provider do far less procedure but integrate their clinical experience with it. Instead of having one angiographer doing all the angios, everyone from nephrologists to cardiologist are doing angios.

I am not going to debate the pro and con of each approach of each approach as this isn’t my thread.

 

[Psai]

Does inventing the procedure make it that specialty's turf if they're not able to manage the perioperative complications? IR also invented PCI but I think we all agree that we'd rather have a Cardiologist with wire skills do these procedures than a physician with maybe even better radiography and wire skills but who is lacking Cardiology knowledge.

lol at using cardiologists as the example for being able to manage perioperative complications. You know how they manage their complications? They call a surgeon: speed dial to vascular or cardiothoracic surgery. And they're starting to teach nurses to do their jobs by teaching them how to do angiography. I will never understand the short sightedness of physicians.

 

[IJL]

Does inventing the procedure make it that specialty's turf if they're not able to manage the perioperative complications? IR also invented PCI but I think we all agree that we'd rather have a Cardiologist with wire skills do these procedures than a physician with maybe even better radiography and wire skills but who is lacking Cardiology knowledge.

The whole managing perioperative complications thing is overblown.

Medicine in the US is very compartmentalized and subspecialized that consults and help from other specialists are the norm. Why don't general surgeons place their own CT guided percutaneous drains for post op abscesses? It was a direct result of their procedure. I'm consulted all the time for pseudoaneurysm thrombin injections after a cardiologist has stuck the groin. Surely they could do that too. Why don't OBGYN's do primary ureteral repairs or place ureteral tubes after they 'ligate' a ureter? Why do orthopods need an internist to manage their diabetic patients? Does a cardiologist really need to call neurology after they caused an embolic stroke after PCI?

In the rare event that IR needs to call a vascular surgeon for help, we have temporizing measures to stabilize the situation. I've never had to do that though after any angio or PAD work.

 

[Jolie South]

The whole managing perioperative complications thing is overblown.

Medicine in the US is very compartmentalized and subspecialized that consults and help from other specialists are the norm. Why don't general surgeons place their own CT guided percutaneous drains for post op abscesses? It was a direct result of their procedure. I'm consulted all the time for pseudoaneurysm thrombin injections after a cardiologist has stuck the groin. Surely they could do that too. Why don't OBGYN's do primary ureteral repairs or place ureteral tubes after they 'ligate' a ureter? Why do orthopods need an internist to manage their diabetic patients? Does a cardiologist really need to call neurology after they caused an embolic stroke after PCI?

In the rare event that IR needs to call a vascular surgeon for help, we have temporizing measures to stabilize the situation. I've never had to do that though after any angio or PAD work.

Oh really? I had to bail out IR yesterday after bleeding from a lysis case. They stood there holding pressure for 2 hours before we got involved. I think the patient has neuropraxia from the pressure on the groin.

It’s not only about managing procedural complications. I got a consult on a patient with tissue loss and PAD who cards saw, admitted, consulted podiatry, ortho, and ID. Then consulted us after they did a crappy quality angio for potential bypass. Does this make sense that 5 specialties should be consulted when a vascular surgeon alone can manage it all? Is that the best use of resources or the best thing for the patient?

And now I have to make surgical decisions based off half ass studies and potentially repeat an angio. The cardiologist doesn’t give a crap if he gives me what I need to do a bypass. And podiatrists only nibble away at toes and where this patient has a wound if it doesn’t improve will need a BKA. Ortho won’t touch because they say this person has a vascular problem and the reason they were consulted is a bone biopsy which they won’t do.

So in the end it’s not good medicine and it’s not good for patients. I trust no one. I want to work up the patient myself and not get a dump when a sub specialist can’t make anymore money off a patient.

 

[IJL]

Oh really? I had to bail out IR yesterday after bleeding from a lysis case. They stood there holding pressure for 2 hours.

It’s not only about managing procedural complications. I got a consult on a patient with tissue loss and PAD who cards saw, admitted, consulted podiatry, ortho, and ID. Then consulted us after they did a crappy quality angio for potential bypass. Does this make sense that 5 specialties should be consulted when a vascular surgeon alone can manage it all? Is that the best use of resources or the best thing for the patient?

And now I have to make surgical decisions based off half ass studies and potentially repeat an angio. The cardiologist doesn’t give a crap if he gives me what I need to do a bypass. And podiatrists only nibble away at toes and where this patient has a wound if it doesn’t improve will need a BKA. Ortho won’t touch because they say this person has a vascular problem.

So in the end it’s not good medicine and it’s not good for patients.

But this won’t make the cardiologist any money so it continues to happen.

We (IR) bail out other services all the time. That wasn't my point. No one service can manage everything in medicine.

I agree, arterial disease probably is best managed by vascular surgeons. But that is based on my anecdotal experience is that there is a lot of bad peripheral arterial work being done out there. You have to know when to say no and when to refer to vascular.

 

[DrfluffyMD]

We (IR) bail out other services all the time. That wasn't my point. No one service can manage everything in medicine.

I agree, arterial disease probably is best managed by vascular surgeons. But that is based on my anecdotal experience is that there is a lot of bad peripheral arterial work being done out there. You have to know when to say no and when to refer to vascular.

Oh really? I had to bail out IR yesterday after bleeding from a lysis case. They stood there holding pressure for 2 hours before we got involved. I think the patient has neuropraxia from the pressure on the groin.

It’s not only about managing procedural complications. I got a consult on a patient with tissue loss and PAD who cards saw, admitted, consulted podiatry, ortho, and ID. Then consulted us after they did a crappy quality angio for potential bypass. Does this make sense that 5 specialties should be consulted when a vascular surgeon alone can manage it all? Is that the best use of resources or the best thing for the patient?

And now I have to make surgical decisions based off half ass studies and potentially repeat an angio. The cardiologist doesn’t give a crap if he gives me what I need to do a bypass. And podiatrists only nibble away at toes and where this patient has a wound if it doesn’t improve will need a BKA. Ortho won’t touch because they say this person has a vascular problem and the reason they were consulted is a bone biopsy which they won’t do.

So in the end it’s not good medicine and it’s not good for patients. I trust no one. I want to work up the patient myself and not get a dump when a sub specialist can’t make anymore money off a patient.

I think it’s less about the subspecialist and more about the indivdual physician’s training. One of the big academic hospital I am familar with have a surgical service who would only trust IR to do their arterial work due to distrustinh their vascular surgery service....

You can always toss out anecodotes to suggest one thing or the other.

 

[IJL]

I think it’s less about the subspecialist and more about the indivdual physician’s training. One of the big academic hospital I am familar with have a surgical service who would only trust IR to do their arterial work due to distrustinh their vascular surgery service....

You can always toss out anecodotes to suggest one thing or the other.

good point

 

[DrfluffyMD]

Point is, some work are highly contested, and people always want to claim it as their own. But I think we need to take a step back and realize the best thing we can do is to do the best thing for our patients. The best thing we can do is to provide the most expert, clinical driven and just straight up good care.

Great endovascular therapy is great endovascular therapy doesn’t matter who do it.

And to need others help isn’t something to be ashamed of unless excessive.

Take access complications, for example. I am an IR. Surgeons refuse to train me to do a cut down or primary femoral arterial repair (I would love to learn). What options do I have besides holding pressure for specific type of access complications when percutaneus options like closure device, covered graft or balloon occlusion isn’t possible? My only option would be to immediatey ask for surgical help. Just like my surgical colleague would ask for my help in the case of an abscess.

 

[Jolie South]

Point is, some work are highly contested, and people always want to claim it as their own. But I think we need to take a step back and realize the best thing we can do is to do the best thing for our patients. The best thing we can do is to provide the most expert, clinical driven and just straight up good care.

Great endovascular therapy is great endovascular therapy doesn’t matter who do it.

And to need others help isn’t something to be ashamed of unless excessive.

Take access complications, for example. I am an IR. Surgeons refuse to train me to do a cut down or primary femoral arterial repair (I would love to learn). What options do I have besides holding pressure for specific type of access complications when percutaneus options like closure device, covered graft or balloon occlusion isn’t possible? My only option would be to immediatey ask for surgical help. Just like my surgical colleague would ask for my help in the case of an abscess.

I am not saying any particular specialty should or shouldn’t do anything. I think people need to realize the limitations that they have and load the boat with the most appropriate specialty as early as possible.

In fact, rely on IR to help us a lot with lysis or diagnostic angios and I have no problem with the work that they do for us. In general, their images are good and they know when to bail and ask for help or come to us for input on certain decisions intra op so they are not burning bridges for us.

I have a problem with a cardiologist getting a patient that they should know from the get go they can’t fix because they will need debridement or amp and admitting primarily and pretending like they can provide the same level of care I can. Or more likely, they want the reimbursement for an angio and don’t care that they can’t do what we do.

 

[evilbooyaa]

Why is cardiology doing any non-cardiac related stuff endovascular stuff? Shouldn't the heart doctors focus on the heart, and the vessel doctors can focus on the vessels? IR and vascular do seem to have a good relationship at most instituions from what I've seen, and I think there's some respect for both of them.

 

[Jolie South]

Why is cardiology doing any non-cardiac related stuff endovascular stuff? Shouldn't the heart doctors focus on the heart, and the vessel doctors can focus on the vessels? IR and vascular do seem to have a good relationship at most instituions from what I've seen, and I think there's some respect for both of them.

In a word, yes.

 

[You shall know the Truth]

What advice would you give to a M1/2 looking to go into a procedural heavy specialty (surgery of all kinds, Cath, IR). A better way is what about vascular surgery convinced you over other specialties?

 

[Oso]

Found this and thought of this thread...

 

[anbuitachi]

I am a first year vascular surgery fellow. Ask me anything about anything from surgery residency to fellowship.

I also didn’t match to my initial subspecialty choice when I first applied way back when and am now happy about it.

How are the outcomes usually for stenting for PVD or bypasses? I literally keep on seeing these vascular patients get angio, plasty, stent, then bypass (then toe amp, TMA, BKA, AKA one after another)and it's like their quality of life doesn't even change. obviously my view is biased because i only see the inpatient side of things. How is the evidence for quality of life improvement for these cases?

 

[Jolie South]

What advice would you give to a M1/2 looking to go into a procedural heavy specialty (surgery of all kinds, Cath, IR). A better way is what about vascular surgery convinced you over other specialties?

I think just practice your suturing and knot tying skills. Some people are more naturally talented than others.

I chose vascular in a round about way as I mentioned above. I applied urology, didn’t match, decided I was not a good fit anyways. Fell into general surgery and then from there chose vascular over other sub specialties because I genuinely like the cases and the wide variety. Plus, there are many career options.

 

[Jolie South]

How are the outcomes usually for stenting for PVD or bypasses? I literally keep on seeing these vascular patients get angio, plasty, stent, then bypass (then toe amp, TMA, BKA, AKA one after another)and it's like their quality of life doesn't even change. obviously my view is biased because i only see the inpatient side of things. How is the evidence for quality of life improvement for these cases?

It depends on a lot of factors. What are the lesions you are treating? How able is the patient to get bypass? Is the patient controlling their comorbidities and quitting smoking?

We are able to stall the process but not cure it unfortunately. I am ok with that. Many patients end in an amp. This is true.

 

[anbuitachi]

It depends on a lot of factors. What are the lesions you are treating? How able is the patient to get bypass? Is the patient controlling their comorbidities and quitting smoking?

We are able to stall the process but not cure it unfortunately. I am ok with that. Many patients end in an amp. This is true.

Well since we live in america im going to guess no they aren't controlling their comorbidities! 🙂

 

[badasshairday]

Why is cardiology doing any non-cardiac related stuff endovascular stuff? Shouldn't the heart doctors focus on the heart, and the vessel doctors can focus on the vessels? IR and vascular do seem to have a good relationship at most instituions from what I've seen, and I think there's some respect for both of them.

Why? Money, that is why. They have squeezed the golden goose of cardiac angiography dry. I saw an earlier post by the OP about cardio doing a crappy angio before consulting vascular surgery. That is ridiculous. Now they tell you they are doing a fellowship in cardioVASCular medicine. Just a turf grab ploy.

 

[Gorne]

Is it true that women love a vascular man?

 

[TypeADissection]

Is it true that women love a vascular man?

I think you're referring to the "anti-Leriche" man.

 

[Arewestilldoingphrasing?]

How much microsurgery do you guys do?

 

[Jolie South]

How much microsurgery do you guys do?

None.

 

[Jolie South]

Is it true that women love a vascular man?

I am not quite sure what you’re getting at.

 

[Gurby]

That chart is making the rounds on Reddit again - the one with hours of specialties normalized against FM, with vascular surgery far and away in first place for most hours worked.

I know you addressed lifestyle a little bit earlier in the thread, but I wonder if you could share your thoughts a little bit more? You mentioned that you at a cush fellowship - was that a part of your decision to go to that particular program? What do you think life will look like for you as an attending? What sort of career trajectory do you envision for yourself?

Thanks so much!

 

[DarknightX]

Point is, some work are highly contested, and people always want to claim it as their own. But I think we need to take a step back and realize the best thing we can do is to do the best thing for our patients. The best thing we can do is to provide the most expert, clinical driven and just straight up good care.

Great endovascular therapy is great endovascular therapy doesn’t matter who do it.

And to need others help isn’t something to be ashamed of unless excessive.

Take access complications, for example. I am an IR. Surgeons refuse to train me to do a cut down or primary femoral arterial repair (I would love to learn). What options do I have besides holding pressure for specific type of access complications when percutaneus options like closure device, covered graft or balloon occlusion isn’t possible? My only option would be to immediatey ask for surgical help. Just like my surgical colleague would ask for my help in the case of an abscess.

A cut down isn’t just something you can learn without some kind of surgical background. They would literally have to teach you how to operate. Exposure, retracting, dissection, suturing, even how to clamp....these are all skills that that that takes years of surgical training to do.

There’s a huge difference between draining a post op abscess, and having a failed closure device cause bleeding that you’re having trouble controlling. A surgical abscess is something that can be drained at your relative convienence. Your closure device failure forces me to drop what I’m doing, and go take care of it right away. And you have to hope that I’m not tied up in another emergency. See the difference? If you’re using larger sheaths that you can’t manage at the immediate time of the procedure, it’s unfair to just rely on the vascular surgeon to bail you out, unless you have an agreement with them.

 

[xerei]

Thanks for doing this.

I have worked on small research projects in both IR and vascular surgery over the past year. From what I see, I like both. I know they are quite different in many ways, but can you speak to what might drive someone one way or the other? As of now, I think a general surgery residency would give me more training in 'taking care of patients' which is appealing to me (even if it means more hours, calls, emergencies, etc) whereas IR might be more of a technician gig, but lifestyle might be nicer. Any input is appreciated.

 

[Jolie South]

Thanks for doing this.

I have worked on small research projects in both IR and vascular surgery over the past year. From what I see, I like both. I know they are quite different in many ways, but can you speak to what might drive someone one way or the other? As of now, I think a general surgery residency would give me more training in 'taking care of patients' which is appealing to me (even if it means more hours, calls, emergencies, etc) whereas IR might be more of a technician gig, but lifestyle might be nicer. Any input is appreciated.

IR is in essence a technician kind of gig and from, what I have seen, with less complicated, but still necessary cases. You would have no long term follow up with patients. I think they stay busy, but they have call like we do and come in in the middle of the night for emergencies also.

I like sick patients. I like having a variety of cases. I like being in charge of my patients’ care and being able to fix most problems they have and not having to call someone to bail me out. These are the things you can’t get out of IR.

 

[Adrenaline Junky]

Thank you for doing this, I have been searching the forums and have found an interest in Vascular. My question is are there any further sub specialities for Vascular? Also, how much of your cases are emergent/acute patients compared to routine procedures? What are your views on outlook in the future and do you feel that you are fairly compensated? I greatly appreciate you taking time to do an AMA.

 

[Jolie South]

Thank you for doing this, I have been searching the forums and have found an interest in Vascular. My question is are there any further sub specialities for Vascular? Also, how much of your cases are emergent/acute patients compared to routine procedures? What are your views on outlook in the future and do you feel that you are fairly compensated? I greatly appreciate you taking time to do an AMA.

There aren’t any official subspecialties, but in academics and large private practices, people some times develop niche practices (I.e. advanced endovascular aortic, thoracic outlet, thoracoabdominal aneurysms, etc)

I would say emergencies are 20% or less of case volume where I am, which is quasi academic high volume private practice. There is a lot of bread and butter elective stuff to do though.

Outlook is great. Old vascular surgeons are retiring and there is already a huge demand. Starting salary of $500k is not unreasonable and could be higher outside of major metropolitain areas where demand is even greater.

 

[LebronManning]

Do surgeons who specialize after GS keep their GS skills in case they ever want to increase business in the future? For example, say one does a fellowship in Vascular and for whatever reason the demand becomes low in their area. Could you just decide to do some GS cases after not having done them for 10 years?

 

[TypeADissection]

Could you just decide to do some GS cases after not having done them for 10 years?

Short answer is yes. You could. But for me personally, that’s a haaaaaaayyyyyyyyllllllllll no. After not having done general surgery for a decade I couldn’t imagine anything worse than getting calls for dislodged peg tubes, Fournier’s, free air, etc. I’m already one month into fellowship and don’t miss general surgery. Please never call me with a SBO vs early pSBO vs ileus ever again. But seriously, it’s gonna be hard getting privileges to do hernias and gallbladder’s when you haven’t done them in a while. Or staying current with breast cancer. Not for me.

 

[Adrenaline Junky]

Typically, how long are vascular cases? Additionally, how did you get used to standing for long hours considering the strain on ones feet and back?

 

[Jolie South]

Do surgeons who specialize after GS keep their GS skills in case they ever want to increase business in the future? For example, say one does a fellowship in Vascular and for whatever reason the demand becomes low in their area. Could you just decide to do some GS cases after not having done them for 10 years?

You can have a perfectly fine career doing nothing but vascular if you want. If you move to a rural area and want to do GS too, you can.

Most vascular surgeons only do vascular.

I think it is not wise to do a case you haven’t done for 10 years if you haven’t kept current on GS.

 

[AnatomyGrey12]

How imperative is vascular specific research? I’ve been fortunate at a DO school to have good success finding research but I’ve been doing essentially everything that I can get my hands on and none of the projects are vascular specific, although many of the projects are in various surgical fields with one being a broad surgical paper I have high hopes for journal wise.